Melanoma is the most serious form of skin cancer in terms of mortality. It may develop anywhere on the skin, and within a pre-existing mole in 30-50% of cases. The commonest sites are the trunk in men, and the legs and trunk in women. The single most important cause of melanoma is exposure to the ultraviolet rays of the sun, especially episodes of sunburn. Furthermore, there is a strong link between episodes of sunburn in childhood and the subsequent development of melanoma. The cancer-inducing damage to the genetic material (DNA) in the skin sustained with each episode of sunburn is irreversible. As a consequence, this cumulative damage tends to translate into skin cancer decades later.

Melanoma normally appears as a brown/black patch or lump with irregular features. The ABCDE criteria provide a useful guide for diagnosing melanoma.
A- Asymmetry (melanoma is asymmetrical i.e. it cannot be divided into 2 equal halves)
B- Border (melanoma has an irregular indented border as opposed to a smooth rounded border)
C- Colour (melanoma consists of more than one shade as opposed to one uniform colour)
D- Diameter (melanoma is usually larger than 6mm in diameter. This last criterion is only valid in the presence of an abnormal shape and colour)
E- Evolution (recent change in size, shape and colour, spontaneous bleeding, and irritation)

*Whether a mole is flat or raised, whether it has gradually become fleshier over a long period, or whether it has hairs protruding is not an indicator of melanoma.


What are the other harmful effects of the sun on the skin?
Besides melanoma, the sun induces other forms of skin cancer, which though not usually fatal, often produce significant disfigurement. The sun’s ultraviolet rays also cause premature ageing of the skin in the form of wrinkles, blemishes, coarseness, broken veins, and scaly patches.

Who has the highest risk of getting melanoma?
The risk of developing melanoma is higher in somebody with fair skin that burns and freckles easily, and in those with numerous moles.  A history of sunburn especially in childhood and adolescence, and a history of melanoma in another family member also contribute to a higher risk of melanoma. Melanoma can occur at any age, however it is extremely rare in childhood.

How common is Melanoma worldwide?
Melanoma is less common than other skin cancers. However, it is much more dangerous and causes the majority (75%) of deaths related to skin cancer. Worldwide, doctors diagnose about 160,000 new cases of melanoma yearly. The diagnosis is more frequent in women than in men and is particularly common among Caucasians living in sunny climates, with high rates of incidence in Australia, New Zealand, North America, and northern Europe.  According to a World Health Organisation (WHO) report about 48,000 melanoma related deaths occur worldwide per year (2006).

In Macedonia in 2015 from melanoma 67 people died at a rate of 3.2 per 100 000 inhabitants, of which 40 are men and 27 are women. The rate of incidence in men is 3.9/100 000 men and 2,6 deaths per 100 000 women.

The age-adjusted incidence rates for melanoma have been increasing in most fair-skinned populations in recent decades.


What has caused the increasing incidence of Melanoma?
Apart from the ozone layer depletion, people’s behaviour in the sun has been the main cause for the rise in skin cancer rates in recent decades. An increase in the popularity of outdoor activities and sunbathing has led to excessive UV exposure. Many people consider sunbathing to be a pleasurable social pastime and unfortunately, even perceive a suntan as a symbol of attractiveness and good health. However, a suntan is merely a sign of UV damage and represents the skin’s attempt to minimize further harm.

How dangerous is Melanoma?
Melanoma skin cancer invades the skin and can spread to other organs in the body, often with fatal consequences. Surgical removal of a melanoma caught in an early stage (thin melanoma) leads to an excellent survival rate in the region of 90-95% at 5 years. However, the chances of survival once a melanoma has spread beyond the skin are dismal. In the Maltese Islands, a total of 617 cases of Invasive Malignant Melanoma were diagnosed in the 19 year period 1993-2011 (270 males, 347 females), and there were 107 deaths (57 males, 50 females) reported from Melanoma during the same period, thus translating into an overall 17.3% mortality rate. This means that around 1 in 6 persons with Melanoma in the Maltese Islands are being diagnosed too late!

How can the chances of survival from Melanoma be improved?
The key to a favourable outcome is early detection and timely surgical treatment. Periodic self-examination of the skin in addition to seeking medical attention when in doubt should become standard practice if we expect to keep the mortality rate from Melanoma at the lowest possible level.

Can Melanoma be prevented?
The genetically determined risk factors for Melanoma, such as having a fair complexion, numerous moles, and a family history of Melanoma cannot be modified or eradicated. However, we can significantly cut down on the risk of developing Melanoma by minimizing exposure to a major environmental hazard, that is, the sun’s ultraviolet radiation. Above all, one should aim to prevent sunburn (tender red skin with or without blistering resulting from acute over-exposure to sun), and special attention should be focused on children and adolescents in view of their vulnerable characteristics.

How can you achieve effective sunscreen?

Clothes are the best protection from sun and should be made of lightweight, tightly woven fabrics with bright color, and sleeves and trouser should be as long as they can. A hat with a wide brim provides good sun protection for eyes, ears, face, back or neck. Sunglasses that provide 99-100 percent UV – A and UV – B protection will greatly reduce eye damage from sun exposure. To use high-quality sunscreen with a protection factor (SPF) at least 30, with waterproof formula. The protective means are necessary used even when going outdoors for only a short time. The protective funds should be applied at least 30 minutes before sun exposure and should be added frequently (every two hours), especially after swimming, sweating and wiping with a cloth. Apply it on the skin smooth and thick layer. Special attention should be paid to the lips, eyebrows and ears. Do not forget the sunlight reflexion on different surfaces, like snow, water, sand, concrete, grass and penetration through the clouds. Protective cream should be used even if the weather is cloudy. Persons exposed at risk of developing skin cancer (eg. People with red or blond hair and light skin, people with many moles, people who have healed themselves from skin cancer, etc.) should protect the skin throughout the whole year.

How can one cut down on exposure to UV rays?
This can be achieved through a combination of two strategies: (a) avoid being outdoors as much as possible when the sun is most intense i.e. 11.00am to 4.00pm,
(b) cover up against harmful UV radiation if one cannot help being outdoors during the hours of peak sunshine, such as in the case of persons having a predominantly outdoor occupation. Sun protection is not only necessary on the beach or by the swimming pool but applies to all outdoor settings. In many situations, sunburn takes people by surprise due to failure in recognising the need for protection, particularly in springtime. Children can be exposed to intense sunlight on the balcony at home, during school breaks, and during outdoor sporting activities. Transmission of sun’s rays through car windows is also significant.


How does one achieve effective sun protection?
As a rule, one should apply a sunscreen factor 20+ (30+ in children) generously every 2-3 hours, cover up with appropriate clothing (e.g. short sleeved better than sleeveless top, and material preferably tightly woven), a wide brimmed hat, and wear Polaroid sunglasses (since UV rays are also harmful to the eyes). There now exist on the market (even in Malta) clothing, including swimwear, with inbuilt sun protection (up to factor 50) for children. It should be stressed that being under an umbrella in an open environment such as at the beach will still lead to sunburn from reflected UV rays unless  additional sun protection measures are employed. Likewise, the sun’s rays do penetrate clouds in significant amounts, and hence one is still prone to sunburn even on overcast spring/summer days.

Is it safe to stay in the sun for long periods as long as one is wearing sunscreen?
A total sunblock in the real sense of the word does not yet exist. Variable amounts of longer wavelength UV rays (UVA) do not get filtered by currently available sunscreens in spite of the high factor formulations that exist. The cumulative effect of these unfiltered rays can still lead to skin cancer and premature ageing of the skin. Therefore, sunscreen application should be combined with sun protective clothing. Above all, one should not overstay in the sun under the false impression that the sun’s rays are completely blocked by sunscreen.

Is a fake tan safer than a suntan?
A fake tan is by far safer than a suntan. A fake tan produces an almost- natural looking tan through a chemical reaction in the skin. It therefore gives the desired cosmetic result in someone who is very keen to have a tan, without one having to sunbathe. Application of fake tan needs to be carried out every 1-2 weeks in order to maintain the tan since the top layers of the skin are constantly being renewed. There are nowadays several fake tan brands on the market as well as a number of salons offering airbrush tanning. It must be pointed out that the fake tan does not offer any protection against the sun and therefore one would still need to adopt the usual sun protection measures.

Is it ok to get an artificial tan from a tanning bed or booth?
One word of warning about tanning beds and booths, which are increasingly promoted locally by a number of health spas and salons. These units induce skin tanning by means of Ultraviolet A radiation which although is very efficient in tanning the skin without burning, it still increases the risk of skin cancer in a significant way, and no doubt is extremely efficient in bringing about premature skin ageing. Clients enquiring about artificial tanning facilities have a right to be explicitly informed about such risks by operators of these units. Something that perhaps most people may not be aware of is that a tan acquired from these tanning units does not protect your skin from sunburn when they go out in the sun (since Ultraviolet B rays are responsible for sunburn).

What is the Ultraviolet (UV) index?
The UV index is nowadays an integral part of the local weather forecast. It is an indicator of the intensity of harmful UV rays around midday. The index ranges from 0 to 11+ and is an excellent guide to the recommended level of sun protection on a day-to-day basis:
UV index  Category Recommended sun protection
0-2  Minimal Wear a hat
3-4  Low  Wear a hat & sunscreen SPF 20+
5-6  Moderate Wear a hat, sunscreen SPF 20+,stay in shade 11am-4pm
7-9  High  As above & preferably stay indoors 11am-4pm
10-11+  Very High As above & greater effort to stay indoors 11am-4pm

Source: Dermatology Department, Sir Paul Boffa Hospital